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Wang TT, Lee CC, Gross AJ, Hajibandeh JT, Peacock ZS. Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures? J Oral Maxillofac Surg 2024; 82:554-562. [PMID: 38403271 DOI: 10.1016/j.joms.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives. PURPOSE To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures. METHODS This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded. PREDICTOR The primary predictor variable was primary payer (public, private, self-pay, and other/no charge). OUTCOME VARIABLE The primary outcome variable was hospital admission (yes/no). COVARIATES Covariates included patient-, medical/injury-, and hospital-related variables. ANALYSES Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant. RESULTS The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission. CONCLUSIONS In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.
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Affiliation(s)
- Tim T Wang
- Resident, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Cameron C Lee
- Head and Neck Oncology Fellow, University of Maryland Medical Center, Baltimore, MD; Clinical Research Fellow, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew J Gross
- Pediatric Craniomaxillofacial Clinical and Research Fellow, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey T Hajibandeh
- Instructor and Director of Quality & Safety, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Zachary S Peacock
- Chair, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA.
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Hughes D, Ng SM, Smyth D, Patel H, Kent S, Henry A, Blore C, Dawoud B, Kumar D, Jefferies C, Kyzas P, Collaborators MTR. Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study. Ann R Coll Surg Engl 2023; 105:461-468. [PMID: 35904336 PMCID: PMC10149241 DOI: 10.1308/rcsann.2022.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures. METHODS A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications. RESULTS Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030). CONCLUSION Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.
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Affiliation(s)
| | - SM Ng
- Kings College Hospital, UK
| | | | | | - S Kent
- University Hospital of Wales, UK
| | - A Henry
- Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, UK
| | - C Blore
- University Hospitals of North Midlands NHS Trust, UK
| | | | - D Kumar
- Liverpool Medical School, UK
| | | | - P Kyzas
- East Lancashire Hospitals NHS Trust, UK
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Lee CC, Wang TT, Gandotra S, Hajibandeh JT, Peacock ZS. Interfacility Emergency Department Transfer for Mandibular Fractures in the United States. J Oral Maxillofac Surg 2022; 80:1757-1768. [DOI: 10.1016/j.joms.2022.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022]
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Shurley CD, Abramowicz S, Manhan AJ, Roser SM, Amin D. Comprehensive analysis of patients with failure of mandibular hardware. Oral Surg Oral Med Oral Pathol Oral Radiol 2022; 134:15-19. [PMID: 35153183 DOI: 10.1016/j.oooo.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of the study was to characterize patients who had failure of mandibular hardware (FMH). STUDY DESIGN This retrospective cohort study consisted of patients with mandible fractures (MFs) that required surgical intervention from 2012 to 2020. Patients were included when mandibular hardware failed. Descriptive variables were collected. RESULTS During the study period, 57 patients (47 male, average age 38.7 years) met the inclusion criteria. Incidence of FMH was 7.4%. Most patients were African American (n = 45, 78.9%) with American Society of Anesthesiologists classification II (n = 40, 70.2%). Tobacco use (n = 31, 54.4%) and/or alcohol (n = 33, 57.9%). The most common etiology was assault (n = 28, 49.1%). The most common location was the angle of the mandible. Most mandibles had fracture at 1 location (n = 31, 54.4%) and a tooth was involved in the fracture line (n = 44, 77.2%). More than half of patients were treated with transoral surgical approach (n = 35, 61.4%). The majority of patients received preoperative antibiotics (n = 51, 89.4%). Patients had varying levels of compliance with postoperative care, and most were not compliant. Infection (n = 45) was the most common presentation of FMH. CONCLUSION High American Society of Anesthesiologists score, smoking, excessive alcohol use, parafunctional habits, and compliance with postoperative instructions may affect surgical outcome.
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Affiliation(s)
- Christine D Shurley
- Resident-in-training, Oral and Maxillofacial Surgery, Emory University School of Medicine
| | - Shelly Abramowicz
- Associate Professor in Oral and Maxillofacial Surgery and Pediatrics, Emory University School of Medicine; Chief of Oral and Maxillofacial Surgery, Children's Healthcare of Atlanta
| | - Andrew J Manhan
- Medical Student Researcher, Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital
| | - Steven M Roser
- DeLos Hill Chair and Professor of Surgery, Department of Surgery, Emory University School of Medicine Emory University; Program Director of Oral and Maxillofacial Surgery and Service Chief of Oral and Maxillofacial Surgery, Grady Memorial Hospital
| | - Dina Amin
- Assistant Professor in Oral and Maxillofacial Surgery, Emory University School of Medicine; Director of Oral and Maxillofacial Surgery Outpatient Clinic, Grady Memorial Hospital, Atlanta, GA, USA.
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Lee CC, Hunter WP, Hajibandeh JT, Peacock ZS. Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair? J Oral Maxillofac Surg 2021; 80:472-480. [PMID: 34732361 DOI: 10.1016/j.joms.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Frailty has been recognized as a predictor of postoperative adverse outcomes in many surgical subspecialties. The purpose of this study was to evaluate the relationship between frailty and complications in patients undergoing operative repair of facial fractures. METHODS The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was frailty as measured by the 5-Factor Modified Frailty Index (mFI-5). The primary outcome variable was the postoperative complication rate. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between frailty and complications. RESULTS During the study period, 4,290 subjects underwent operative repair of a facial fracture. Of these subjects, 4,086 (83.0%) were classified as nonfrail, 626 (12.7%) as moderately frail, and 208 (4.20%) as severely frail. A total of 237 subjects experienced a complication (4.82%), and the incidence of complications increased in a stepwise manner with increasing frailty (P ≤ .001). In multivariate regression, age (P = .050, 95% CI = 1.00 to 1.02), Native Hawaiian/Pacific Islander race (P = .018, 95% CI = 1.23 to 8.63), classification as moderately frail (P = .010, 95% CI = 1.15 to 2.66), classification as severely frail (P = .032, 95% CI = 1.06 to 3.70), mandibular fractures (P = .004, 95% CI = 1.24 to 2.98), and wound classification as contaminated (P ≤ .001, 95% CI = 1.53 to 4.57) or dirty/infected (P = .020, 95% CI = 1.16 to 5.55) were independent predictors of complications. Severely frail subjects also had greater length of hospital admission (P ≤ .001) and higher 30-day readmission rates (P ≤ .001). CONCLUSIONS Frailty is an independent predictor of complications following facial fracture repair and is associated with greater length of hospital admission and 30-day readmission rates.
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Affiliation(s)
- Cameron C Lee
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | | | - Jeffrey T Hajibandeh
- Instructor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - Zachary S Peacock
- Associate Professor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
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Lee CC, Hajibandeh JT, Tannyhill RJ, Peacock ZS. Is Outpatient Management of Mandibular Fractures Associated With Inflammatory Complications? An ACS-NSQIP Study. J Oral Maxillofac Surg 2021; 79:2507-2518. [PMID: 33964241 DOI: 10.1016/j.joms.2021.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Timing of mandibular fracture repair has long been debated. The purpose of the present study was to assess the incidence of postoperative inflammatory complications (POICs) following open repair of mandibular fractures managed non-urgently in the outpatient setting versus urgently in the inpatient setting. METHODS The authors utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to enroll a sample of patients with mandibular fractures who underwent open repair. The primary independent variable was treatment protocol: outpatient (elective) versus inpatient (urgent/non-elective). The primary dependent variable was POIC (yes/no). Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between treatment protocol and POICs. RESULTS The study cohort was comprised of 1,848 subjects with 1,134 outpatients and 714 inpatients. The incidence of POICs was 6.53% for the outpatient group compared to 8.96% for the inpatient group, with no significant difference between groups (P= .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01 to 4.83), ASA III (P = .020, OR = 2.88, 95% CI 1.18 to 7.02), diabetes (P = 0.004, OR = 3.11, 95% CI 1.43 to 6.74), and preoperative hematocrit (P = 0.010, OR = 0.950, 95% CI 0.913 to 0.988) were independent predictors of POICs. Length of stay was 0.83 ± 2.61 days compared to 2.36 ± 3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001). CONCLUSIONS There was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a shorter length of hospital stay.
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Affiliation(s)
- Cameron C Lee
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA
| | - Jeffrey T Hajibandeh
- Instructor, Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - R John Tannyhill
- Instructor, Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - Zachary S Peacock
- Assistant Professor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
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Nishimoto RN, Dodson TB, Dillon JK, Lustofin SV, Lang MS. Is Distance Between Home and Treatment Site a Risk Factor for Complications After Treating Mandibular Fractures? J Oral Maxillofac Surg 2021; 79:1528.e1-1528.e8. [PMID: 33773968 DOI: 10.1016/j.joms.2021.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Our level I trauma center provides care over a large geographic area including Alaska, Washington, Idaho, Montana, and Wyoming, with many patients traveling hundreds of miles to receive care. Distance to a treatment site is documented to be an independent risk factor for complications after multisystem trauma, but it is unclear if it is a risk factor for isolated mandibular fractures. The study purpose was to measure the association between distance to treatment site and risk for postoperative complications after treatment of isolated mandibular fractures. MATERIALS AND METHODS The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center by the oral and maxillofacial surgery service between June 2012 and December 2016. The primary predictor variable was distance (miles) between the patient's residence and site of treatment (Harborview Medical Center). The primary outcome variable was postoperative complication (yes or no), subcategorized as major and minor. Secondary outcome variables were time to treatment between injury and operative treatment (days) and length of hospital stay (LOS) (days). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between distance to treatment site and postoperative complications, time to treatment, and LOS. The level of statistical significance was set at P ≤ .05. RESULTS The study sample was composed of 403 subjects with a mean age of 32.6 ± 14.3 years and 80% were men. The average distance from the patient's residence to treatment site was 44.8 ± 128.6 miles (range, 0 to 1,440 miles; median, 20.4 miles). Major complications occurred in 11.6% of patients. The average distance between patients with and without postoperative complications was not significantly different (42.3 ± 55.8 miles vs 45.5 ± 141.7 miles; P = .8). Increasing distance was significantly associated with longer LOS (r = 0.16; P < .001) but not time to treatment (r = .04; P = .4). CONCLUSIONS In contrast to other studies regarding multisystem trauma, complications after treating isolated mandible fractures were not associated with increasing distance to treatment site. Increasing distance may be associated with longer LOS but not time to treatment.
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Affiliation(s)
- Rodney N Nishimoto
- Resident, Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA.
| | - Thomas B Dodson
- Professor and Chairman, Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA
| | - Jasjit K Dillon
- Clinical Associate Professor, Program Director, Chief of Service, Harborview Medical Center, University of Washington School of Dentistry, Seattle, WA
| | - Stephanie V Lustofin
- Resident, Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA
| | - Melanie S Lang
- Clinical Associate Professor, Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA
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